Provider Demographics
NPI:1912935859
Name:LONGFELLOW, CHAD EVERETT (DC)
Entity Type:Individual
Prefix:DR
First Name:CHAD
Middle Name:EVERETT
Last Name:LONGFELLOW
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 E HIGH ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:OH
Mailing Address - Zip Code:43050-3420
Mailing Address - Country:US
Mailing Address - Phone:740-392-4878
Mailing Address - Fax:740-392-6894
Practice Address - Street 1:306 E HIGH ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:OH
Practice Address - Zip Code:43050-3420
Practice Address - Country:US
Practice Address - Phone:740-392-4878
Practice Address - Fax:740-392-6894
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-29
Last Update Date:2009-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1575111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000503889OtherANTHEM PROVIDER #
OH2719133Medicaid
OH000000503889OtherANTHEM PROVIDER #
OHLO9366411Medicare PIN